News Scan for Aug 31, 2021

News brief

COVID vaccine doses may have weaker effect in immune-compromised

After two doses of an mRNA-based COVID-19 vaccine, nearly 90% of immunocompromised patients had an antibody response, but it was about as third as strong as those with healthy immune systems, according to data published in the Annals of Internal Medicine yesterday.

Researchers recruited 133 adults who were receiving immunosuppressive therapies for chronic inflammatory diseases (CIDs) plus 53 adults with healthy immune systems from the San Francisco and St. Louis areas. The most common CIDs were irritable bowel syndrome (31.6%) and rheumatoid arthritis (28.6%). All received two doses of the Pfizer/BioNTech or Moderna vaccine from Dec 1, 2020, to Mar 20, 2021, and they gave blood samples 2 weeks prior to their first dose and within 3 weeks after the second dose.

All 53 patients with non-compromised immune systems developed sufficient antibodies, whereas 88.7% of immunocompromised patients did. The researchers note, however, that the geometric mean titers at half-maximal neutralization were 6,261 in the healthy group, compared with 2,312 in the immunocompromised group.

Those who were on glucocorticoids (17) and B-cell depletion therapy (10) also showed lower anti-spike protein immunoglobulin G (Anti-S IgG) antibody titers. For instance, those on prednisone had a geometric mean titer of 357 anti-S IgG, compared with 2,190 in non-users, and only 65% were seropositive after vaccination. As for those on B-cell depleting therapies, only 60% appeared to have immunogenicity, with less likelihood if therapy occurred within 6 months.

"What we found here is that the vast majority of immunocompromised patients with autoimmune diseases are able to mount antibody responses following COVID-19 vaccination. There’s clearly a benefit for this population," said co-senior author Alfred Kim, MD, PhD, in a Washington University press release. The researchers plan to follow up with this cohort as some choose to get a third vaccine dose.
Aug 30 Ann Intern Med study
Aug 30 Washington University
press release


MIS-C mostly resolves 1 year later, study says

Of 68 UK patients with multisystem inflammatory syndrome in children (MIS-C) tied to COVID-19, most had resolved symptoms 1 year after hospitalization, according to a research letter yesterday in JAMA Pediatrics.

The cohort had been admitted to the hospital prior to May 10, 2020, and follow-ups in April 2021 showed that many symptoms resolved. While two patients (3%) had to be readmitted to critical care for a median hospitalization of 10 days, none needed respiratory support after discharge, and all instances were unrelated to MIS-C. No deaths occurred.

Of the inflammation biomarkers C-reactive protein, D-dimer, and troponin, 3%, 3%, and 2% of tests came back abnormal 50 days post-admission, respectively, although the researchers note that only 59 to 65 of the cohort were tested for each. Blood results for lymphocytes, neutrophils, platelets, creatinine, ferritin, and alanine transaminase were normal for all more than 50 days post-admission.

Aneurysms were resolved in 14 of 19 patients. All patients with impaired function without aneurysm recovered by day 74.

"While the majority of the units have established a consistent multidisciplinary follow-up protocol, this analysis is restricted to one of the earliest reported cohorts of patients worldwide, when the presence of such an entity was becoming apparent," write the researchers. "Although our data identify a group of patients with a risk of significant long-term morbidity, it is reassuring that the majority of patients had good outcomes with no significant medium- or long-term sequelae."
Aug 30 JAMA Pediatr study

Stewardship / Resistance Scan for Aug 31, 2021

News brief

Survey: Those with minor symptoms more likely to OK delayed antibiotics

Severity and the type of symptoms experienced appear to be the biggest factors in accepting a delayed antibiotic prescription for a respiratory tract infection (RTI), according to a UK survey published yesterday in PLOS Medicine.

The survey, completed by 802 adults and 801 parents in the United Kingdom, presented respondents with 12 hypothetical scenarios in which they or their child might need an antibiotic for an RTI, and whether they would accept an immediate or delayed prescription from their primary care physician. While UK primary care guidelines recommend a delayed prescription for RTIs—under which patients are advised to initiate antibiotics only if their condition worsens—uptake of the practice has been modest, and researchers want to better understand the factors that affect people's decisions.

Non-parent adults were more likely to accept a delayed prescription for minor symptoms like a cough and runny nose (probability, 53%) or a sore throat with swollen glands (47%) than for a sore throat with swollen glands and a fever (37%) or a cough with a fever (30%), and they were less likely to accept a delayed prescription with increasing duration of illness (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.92 to 0.96). Parents showed an even more marked reduction when it came to delaying prescription amid lengthening illness (OR, 0.83).

Women were more likely than men to choose a delayed prescription for minor symptoms (62% probability vs 45% probability). Similar higher probability patterns for delaying prescription for minor symptoms were observed in older adults, those who were knowledgeable about antibiotics, and those who had been prescribed antibiotics in the past year.

The authors of the survey say presenting specific scenarios may have prompted responses that more closely reflect decisions that would be made in real life.

"Our findings could help to reduce consumption of antibiotics in primary care by encouraging primary care physicians to increase their use of delayed prescription in those groups who are more open to this approach and to specifically address concerns such as illness duration," they wrote. "Educational interventions to improve understanding of antibiotics could target those who are less amenable to delayed prescription and focus on the (lack of) role of antibiotics in sore throat."
Aug 30 PLOS Med study


Study links ICU stewardship to small reduction in antibiotic use

A randomized crossover study of antibiotic stewardship rounds (ASRs) in intensive care units (ICUs) found a small but measurable reduction in antibiotic use, Duke University researchers reported yesterday in Clinical Infectious Diseases.

The study involved five adult ICUs at Duke University Hospital from October 2017 to June 2018, and researchers compared antibiotic use during and after ICU stay in units with weekly ASRs and those assigned to routine care. The ASRs involved weekly face-to-face meetings with physicians and pharmacists from the antibiotic stewardship and ICU teams, and discussions of antibiotic optimization for reviewed patients.

The analysis included 4,683 patients, with 2,330 in the intervention group and 2,353 in the control group. Teams performed 761 reviews during ASRs, which excluded 1,569 patients from review.

The rate ratio (RR) of antibiotic use in days of therapy per 1,000 days present was 0.97 (95% CI, 0.91 to 1.04), but there was a large variation in effect size when the analysis was stratified by unit. When the unit with the highest percentage of patients excluded from ASRs (the cardiothoracic ICU) was removed, the RR was 0.93 (95% CI, 0.89 to 0.98). Antibiotic use in all five ICUs in the post-study period declined by 16% compared to antibiotic use in the baseline period, with the largest reduction observed in the neurology ICU (—28%) and the smallest in the cardiothoracic ICU (–2%).

The study authors say the results highlight the importance of customizing antibiotic stewardship strategies to match the patient population, workflow, and culture in each unit. They also note that, because ASRs are such a high-resource intervention, sustainability may be a challenge.

"Thus, future study is needed to develop selection tools that assist in identifying clinical scenarios that are most likely to result in meaningful stewardship interventions to reduce the personnel time required for reviews," they wrote.
Aug 30 Clin Infect Dis abstract

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